Pain Management Handouts - Barkley and Associates Handout Samples/Full Handouts/P… · Pain Management Handouts 1 Pain Management for the Advanced Practice Nurse Elizabeth A. VandeWaa,

Pain Management Handouts

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Pain Management for the Advanced Practice Nurse

Elizabeth A. VandeWaa, PhDLecturer, Barkley and AssociatesUniversity of South AlabamaCollege of Nursing

The Problem of Pain Scope Assessment Treatment Fear Keeping current ….we do not “manage pain”.

To be in charge of; to regulate; to control

The Problem of Pain In some patients, it cannot be

‘managed’ unless the disease process can also be managed. If it cannot…. Carry on in spite of it Deal with it Take care of it Direct it Look after it Supervise it Officiate it Tend to it

Who’s in Pain?Institute of Medicine Estimates that over 116 million Americans

experiences chronic pain syndromes A cost of 600 billion dollars annually Far exceeds the cost to healthcare

economy of that than of diabetes, CV disease

So how to create a culture for quality improvement at the point of care?

Graphic by Abu badali

Three Issues Matching the patient in pain to the correct

treatment Assessment, treatment

Keeping abreast of issues in pain management Medications for pain, adjunctive treatments,

new strategies Recognizing the issues with these medications

and learning best practices to deal with them Dealing with tolerance, abuse, diversion

What Defines the Patient in Pain? Chronicity

Disease process Gender Age Genetics Tolerance

Drug seeker/abuse issues Intractability

Strategies


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Types of Pain Acute Pain: Recent onset, transient, from

an identifiable cause Chronic Pain: Persistent or recurrent;

lasting beyond the usual course of illness or injury or more than 3-6 months, and which adversely affects the individual’s well-being

Breakthrough or Flare-up Pain: Transient pain which is severe or excruciating; unpredictable. May indicate changes in underlying disease.

Classification of Pain Pathophysiology Nociceptive pain is due to tissue injury. Eudynia describes nociceptive pain

Somatic and visceral subtypes Responds well to opiates and NSAIDs

Neuropathic pain results from damage to brain, spinal cord, or peripheral nerves.

Maldynia describes neuropathic pain Responds well to adjuvant analgesics

Photo by Emőke Dénes

Assessment of PainAssess pain location, type of pain (dull,

sharp, stabbing, throbbing, etc.), what makes pain better, worse, how pain changes with time Some patients over-report

Drug seekers Low pain tolerance

Some patient under-report Fear of addiction Fear of treatment Feel a need to be stoic Male patients under-report to female nursing staff

“I Feel Like A Number…” The Oath of Maimonides says "may I never

see in the patient anything but a fellow creature in pain" Although the Numerical Rating Scale is a

useful first step, it may not connect on a human level

“Rate Your Pain”Question….In the patient who cannot self-report pain….• How should the NP assess pain in a patient?

• Rate the patient's pain intensity using the 0-10 numerical or faces pain rating scale

• Ask a family member to rate the patient’s pain intensity using the 0-10 numerical or faces pain scale

• Assume that pain is present on the basis of underlying known painful pathology and care activities

• Use a behavioral assessment tool, such as the Critical Care Pain Observation Tool


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Critical Care Pain Observation Tool

Hierarchy of Pain Measures Attempt to obtain self-report Consider underlying pathology or

conditions and procedures that might be painful

Observe behaviors Evaluate physiologic indicators Conduct an analgesic trial From Pasero C. Challenges in pain assessment. J

Perianesth Nurs. 2009;24:50-54.

Hierarchy of Pain Measures• Attempt to obtain the patient's self-report

• Single most reliable indicator of pain • Many cognitively impaired patients are able to

use a self-report tool, such as the Wong-Baker FACES Scale, Faces Pain Scale-Revised, or Verbal Descriptor Scale.

• Consider the patient's condition or exposure to a procedure that is assumed to be painful. If appropriate, assume pain is present (APP) and document APP when approved by institution policy and procedure.

Hierarchy of Pain Measures• Observe behavioral signs (e.g., facial

expressions, crying, restlessness, and changes in activity). • Behavioral score is not the same as a pain

intensity score. Pain intensity is unknown if the patient is unable to provide it.

• A surrogate who knows the patient well (e.g., parent, spouse, or caregiver) may be able to provide information about underlying painful pathology or behaviors that may indicate pain.

Hierarchy of Pain Measures Evaluate physiologic indicators

The least sensitive indicators of pain May signal the existence of conditions other

than pain or a lack of it (e.g., hypovolemia, blood loss).

Patients may have normal or abnormal vital signs in the presence of severe pain.

The absence of elevated blood pressure or heart rate does not mean the absence of pain.

Hierarchy of Pain Measures• Conduct an analgesic trial to confirm the

presence of pain and to establish a basis for developing a treatment plan. • Administer a low dose of nonopioid or opioid and

observe patient response. • May increase if the previous dose was tolerated, or

another analgesic may be added. If behaviors continue despite optimal analgesic doses, other possible causes should be investigated. In patients who are completely unresponsive, no change in behavior will be evident and the optimized analgesic dose should be continued.


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Areas of Research in Pain That Are Influencing How Pain Meds are Used Age and pain Genetics

Pharmacogenomics Race/ethnicity Monitoring Looking past the opiates as drugs

for pain

Age as a Determinant of Pain Is pain ‘different’ across the lifespan? New studies indicate pediatric pain is

equal to that of adults Analysis and use of pain medications by

teens Pain in the elderly is likely undertreated

Morphine remains the opioid analgesic most commonly used to control moderate-to-severe postoperative pain in neonates.

Surgical procedures after which morphine is given may include craniotomy, thoracotomy, sternotomy, and laparotomy.

Dosing: Incremental IV boluses of 20 mcg/kg, not to exceed 100 mcg/kg, for acute pain management in the postanesthesia recovery unit. If continuous IV infusion is used for postoperative pain management in neonates, the initial rate varies depending on the patient's age.

Neonatal Infant Pain Scale is useful for assessment here.

Neonatal Pain Management Neonatal Pain Management Fentanyl is given by IV infusion to neonates

who are preoperatively ventilated and who are expected to remain ventilated postoperatively. Episodes of apnea are more severe when this drug is administered as an IV bolus of 1-2 mcg/kg than when it is given as a continuous IV infusion of 1-2 mcg/kg/h. Watch for chest wall rigidity

Fentanyl is less likely to cause hypotension than morphine; this may be a positive in the postoperative neonate.

Pediatric Pain Management For children as young as 3 years, the

revised FACES scale, Wong-Baker Faces scale and the 10-cm Visual Analog Scale are useful for assessment

For infants and those with cognitive impairment, use face, legs, activity, crying and consolability (FLACC) scale

Photo by D. Sharon Pruitt from Hill Air Force Base, Utah, USA

Pediatric Pain Management--ER Local anesthetics alone or with vasoconstrictors

are often appropriate for children, infants, and even neonates for painful procedures. In neonates administration of a 12-25% sucrose

solution (pacifier) has been very helpful in reducing response to noxious stimuli.

Sedative hypnotics that are short-acting offer ‘escape’ from pain and procedural sedation in children. Propofol, ketamine


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In One ‘Snapshot’ Study of Teens… Over half reported back pain! Girls reported higher pain levels than boys 52% used drugs including:

• Prescription-strength ibuprofen: 36%• Acetaminophen with codeine: 30%• Acetaminophen and hydrocodone:

12%• Long-acting opioids (such as controlled-

release morphine): 4%.

Pain Medication Use In Teens Likelihood of use of pain meds increased 140-

200% with each grade of high school Girls were more likely than boys to ask a

parent (mother) about using a pain med But only 47% do

Pain scales/intensity were not predictors of use of drugs; having an additional site of pain (headache, backache, sore knees) was a better predictor Each additional site increased odds of use

by 120-150%

Opiates in Pregnancy Linked to: Conoventricular, atrioventricular, and

atrial septal defects Hypoplastic left heart syndrome Tetralogy of Fallot Pulmonary valve stenosis Spina bifida Gastroschisis

Role of Sex in Pain and Analgesia Females experience more painful situations, have a

lower threshold for pain This changes over the lifespan, so hormones may play

a role in the pain response With mu-opioid agonists, women experience more

nausea, vomiting, and respiratory depression than men Morphine seems to have greater potency but slower

onset and offset in women With kappa-opioid agonists, women experience

longer and more intense analgesia Buprenorphine, butorphanol

Prevalence of Pain in the Elderly The Centers for Disease Control and

Prevention (CDC, 2006), the American Geriatrics Society (2002), and the American Pain Foundation (2008) estimate that 21%-70% of community-dwelling older adults (i.e., >60 years of age) experience persistent pain, with a significant tendency toward underreporting. In community-dwelling adults, predominant

pain is musculoskeletal

Trends Seen in Pain Treatment Patients older than 75 are 20% LESS likely

to receive pain meds than adult counterparts. Worry about side effects? Concern about drug interactions? Concern that drug regimens will become

too complicated? This compounds the problem of

underreporting! Interference with QOL activities such as

walking, mood, sleep


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Risks of Opiates in the Elderly Chronic opiate use in the elderly is

associated with immunosuppression. Pneumonia risk has been known to increase as a result.

Elevated risk of compound fracture of the wrist, hips

Increased need for laxative use…and an increased risk for falls

Five percent of all adults over 65 using opiates in chronic regimens have been hospitalized

The Elderly Patient and Pain Meds Women are more likely to take meds than

men Report “poor” or “fair” health Have osteoarthritis Have mobility or ADL difficulty Report that pain definitely affects QOL Use nonpharmacologic strategies—

maybe to their detriment

Ask the patient about pain—considering dx and hx

Search for causes of pain—dx, but also position, constipation, falls, too hot/cold

Seek surrogate reports—not always reliable! Consider diversion!

Empiric analgesic trial Observe behaviors—BODIES

What About the Nonverbal Patient with Dementia?

BODIESMnemonic for Assessment of Pain in Demented and Nonverbal EldersB What behaviors did you see?O How often did the behaviors occur?D What was the duration of behaviors?I How intense were the behaviors?E How effective was the treatment, if

given?S What made the behaviors start or

stop?

Ethnicity and Race In a large meta-analysis of post-op patients, pain

levels were significantly higher among African American children than among Caucasian children, and African American children (especially those with a history of obstructive sleep apnea) required more analgesic interventions and more postoperative morphine than did Caucasian children.

Overall opioid-related adverse effects were 2.8 times more common in Caucasian patients than in African American patients.

Race may determine morphine’s clearance

Genetic Trends in Opiate Response Based on a 121 twin-pair double blind placebo

controlled study… Nausea, slowed breathing and potential for

addiction may be heritable traits Itchiness and sedation are also likely heritable Heritability was found to account for 30 percent

of the variability for respiratory depression, 59 percent of the variability for nausea and 36 percent for drug disliking. Additionally, up to 38 percent for itchiness, 32 percent for dizziness and 26 percent for drug-liking could be due to heritable factors.


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Genetic Trends in Opiate Response Genetics may account for 60% of the

variability in the effectiveness of opiates in relieving pain. “That doesn’t work for me…..” Pharmacogenomics Linked to several genes/alleles/enzymes

OPRM1—gene that encodes the opiate receptor CYP2D6—hepatic enzyme that metabolizes

opiates UGT2B7—hepatic enzyme that metabolizes opiates

Genetic Trends in Opiate Response Recent deaths in children given codeine

highlight the importance of understanding pharmacogenetic-opiate link Likely to blame: Overdose and CYP2D6

ultra rapid metabolism status Other opiates using this enzyme include

tramadol, hydrocodone, oxycodone: They are converted to more potent mu agonists by this enzyme and may require greater rescue analgesia in rapid metabolizers

The Nurse Practitioner and Pain Management

Keeping Current With Drugs to Manage Pain Opiates are and will be mainstays of

chronic pain management Problems associated with use fall into 2

categories Prescriber education, liability, prescriptive

authority User abuse, diversion

Prescription Opiate Facts US consumes 80 % of the world’s opioids and 99% of

the world’s hydrocodone Accidental overdoses of Rx opiates kill more people

in 17 states than do car accidents Males are 1.5 times more likely to become addicted

Prescription Opiate Facts Hydrocodone/APAP is the #1

prescribed drug in the US!!!! 1 in 20 people in US take

opiates for nonmedical use Enough Rx painkillers were

prescribed in 2010 to medicate EVERY adult in the US around–the-clock for one month

Hydrocodone liquid


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Source Patients, %Bought from a dealer 84.2Someone gave them 83.0Bought from a patient who sells their medication

74.7

Legitimate prescription for pain 57.7Stolen 44.1Prescription from physician but no legitimate reason

30.6

Prescription from multiple physicians 23.6Internet 8.9Prescription from physician who prescribes illegally

3.4

Forged prescription 2.8Other source 3.8

Opioid Sources in the Last 6 MonthsNPs and Pain Management The Nurse Practitioner Healthcare

Foundation recently noted goals for NPs: To keep current with multimodal

approaches to chronic pain control To follow evidence-based guidelines to

treat chronic pain in their current practice, particularly with respect to prescribing opioids

Any prescription for a CS will have the NP’s DEA#, denoting the NP’s independent or plenary authority to prescribe within the state’s scope of practice.

Standard Rx information Name, title, license, specialty, ID/Rx #, address,

phone #, all patient information, refill info, generic substitution info

Cosignature of a collaborating physician is NOT required in any state where an NP is authorized to write.

NP Prescriptive Authority To Ensure Safe Practice and Prescribing for NPs American Pain Society and American

Academy of Pain Medicine have put together strategies for safer prescribing

For the patient on Chronic Opiate Therapy (COT)—14 recommendations A thorough history including that of prior

substance abuse Risk/benefit ratio should be explained COT management plan with endpoints

Photo by Evelyn Simak

COT Plan, Continued A plan for continuance of COT Patient monitoring, including urine drug

screens Discuss referral to a specialist if addiction

issues arise Discontinue patients suspected of

diverting Treat opioid ADRs including constipation,

sedation, itching, respiratory depression

COT Plan, Con’t Use of psychotherapeutic cointerventions Educate patients about cognitive changes

caused by COT Patient must have continuous access to a

primary HCP Educate patient about breakthrough pain Educate patient regarding the use of COT (or

NOT) in pregnancy Keep abreast of current treatments and

guidelines and laws


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The Pendulum Swings Issues with pain meds

Overuse Abuse Overprescribing Diversion Across the lifespan Across the medication span

And Swings Again…. Due to fear of addiction, about

25% of patients receive opioids in doses sufficient to relieve suffering. Physical dependence:

Abstinence syndrome will occur if drug is abruptly withdrawn

Abuse: Drug use inconsistent with medical or social norms

Addiction: Continued use of a drug despite physical, psychologic, or social harm

A Quick Review of Opiates Activate mu and kappa receptors

Activation of the mu receptor produces analgesia, sedation, euphoria…but also respiratory depression

Activation of the kappa receptor produces analgesia and sedation

Both receptors are responsible for causing constipation

Drugs are pure agonists, agonist-antagonists (sometimes called partial agonists), or pure antagonists on these receptors Chemical structure of morphine

Examples of Opiates Pure Agonists

Morphine, codeine, meperidine, fentanyl, hydromorphone, methadone, levorphanol, oxymorphone, oxycodone, tapentadol, hydrocodone

Agonist-Antagonists Buprenorphine, butorphanol, nalbuphone,

pentazocine

Adverse Effects of Opiates Respiratory depression

Most common cause of death due to overdose Varies with route: Seven min. after IV, 30 min. after IM,

90 min. after subQ, hours after spinal Reverse with Naloxone

Constipation Prophylaxis with stimulant laxatives may help Methylnaltrexone will reverse GI effects

Hypotension, urinary retention, cough suppression, biliary colic, emesis, elevation of ICP, euphoria/dysphoria, birth defects, sedation, miosis

Opioid Related Deaths


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IR tablets—15, 30 mg CR tablets (MS Contin, Oramorph SR)—15-200 mg ER tablets—15-200 mg SR tablets (Kadian)—10-200 mg ER capsules (Avinza)—30-120 mg Standard oral solution (MSIR)—10 and 20 mg/5mL Concentrated oral solution (MSIR, Roxanol)—100mg/5mL Rectal suppositories (RMS)—5-30 mg Soluble tablets for injection—10-30 mg Standard solution for injection (Astramorph PF, Duramorph,

Infumorph)—0.5-50 mg/mL Extended release liposomal solution for injection (DepoDur)—

10 mg/mL Morphine/Naltrexone (Embeda)

Morphine Preps Fentanyl Sublimaze, Duragesic, Abstral, Actiq, Fentora, Onsolis,

Lazanda 100 times more potent than Morphine Watch with coadministration of other CYP3A4 inhibitors

(ritonavir, ketoconazole) as adverse effects will increase Parenteral use for maintenance of anesthesia Patch wearers need to be opiate tolerant; no heat on the

patch Transmucosal, nasal preps approved for breakthrough

cancer pain only in opiate tolerant patients

Other Strong Opioids Meperidine

May accumulate as a toxic metabolite, so dosing should not exceed 600mg/24h. Some utility for patients with post-anesthesia shivering.

Methadone Long duration of action, but prolongs the QT interval.

Avoid use in patients taking amiodarone, TCAs, erythromycin, quinidine. Patients need ECG prior to and 30 days after treatment. Stop treatment if QT interval exceeds 500 msec.

Avoid concomitant use of CNS depressants

Other Opiate Agonists Codeine

About 10% gets metabolized to morphine in the body by CYP2D6. Individuals who are ultrarapidmetabolizers may have an increase in analgesia or adverse effects.

Dosing is PO, IV, IM, SubQ. Usual adult dose is 15-60 mg/3-6 h (max 120mg/24h). Pediatric dose is 0.5 mg/kg PO, IM or SubQ every 4-6 h (max 60 mg/24h)

CYP2D6 structure

Other Opiate Agonists Hydrocodone

Vicodin, Vicoprofen, Lortab Analgesia equivalent to codeine Most widely prescribed drug in the US Usual dose is 5 mg; acetaminophen dose should

be less than 4 g/day (less in liver disease). Ibuprofen preps should be limited to 5 tablets a day and no more than 10 days.

Oxycodone OxyContin, Roxicodone, Combunox, Oxecta,

Percocet, Percodan Analgesia equivalent to codeine. Patients must be

opiate-tolerant to get 80 mg strength. Metabolized by CYP3A4 so watch concomitant use of

inhibitors/inducers of this enzyme Oxycodone has been reformulated to be impossible

to inject. Oxecta will burn nose if snorted, and forms a gel if put in

solution FDA labeling changed to note this; no generics

Other Opiate AgonistsOxycodone chemical structure


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Agonist-Antagonist Opiates Pentazocine (Talwin)

Agonist at kappa, antagonist at mu Little euphoria, limited respiratory

depression, but increases cardiac work Nalbuphine (Nubain)

Agonist at kappa, antagonist at mu Not a CS; injectable only Has a ceiling for pain relief

Butorphanol (Stadol) Agonist at kappa, antagonist at mu Analgesia less than morphine, low abuse potential, CS-

IV Increases cardiac work Parenteral (IM, IV) and nasal spray

Buprenorphine (Buprenex, Butrans, Subutex, Suboxone) Partial agonist at mu, antagonist at kappa Analgesia like morphine, less tolerance, some

respiratory depression, hard to reverse toxicity with naloxone, prolongs QT, cause biliary colic.

Butrans is patch formulation with strict guidelines for patch site rotation; lowest dose may be used in opioid naïve patients. Initial 5 mcg/h patch every 7 days

Agonist-Antagonist Opiates

Agonist-Antagonist Opiates Buprenorphine, Con’t.

Buprenex is given by IM or IV injection (0.3 mg) every 6 hours as needed

Subutex are PO tablets containing 2 or 8 mg buprenorphine

Suboxone is tablets or films that contain the drug plus naloxone used for managing opioid addiction—or off-label for pain. For addiction, dosing is once-a-day For analgesia, dosing is 3-4 times/day

Photo by Supertheman

Oxycodone plus Naloxone Targinact: For chronic pain Offsets opioid-induced constipation Targinact was designed to reduce the challenge

of opioid-induced constipation in chronic pain management. Naloxone PO is metabolized in the liver, so that

peripheral antagonism of opioids exists in the gut, but after that, little naloxone passes into the central nervous system.

Opioid Antagonists as Adjuncts Methylnaltrexone (Relistor, s.c. dose: 150 mg

kg−1, given once a day). For opioid-induced constipation in advanced

wasting illness Alvimopan (Entereg, 12 mg) mu receptor

antagonist given by mouth just before surgery and then another 12 mg dose given twice daily for up to 7 days, with a maximum dose of 15 capsules. This preparation was designed to address the

problem of opiate-induced constipation after intestinal surgery. Bowel recovery time ranged from 10 to 26 hours shorter for patients who were given alvimopan.

With Respect to Costs… Prescription drug abuse accounts for 1

million ED visits/year Equal to the number due to illegal drugs

Sixty percent of hospital costs related to opioid overdoses are paid for with public funds

What to do?


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What To Do? Team-BasedApproach to Prescribing Institute clear policies and stick to those

policies. If patients report that their medications

have been stolen, require that they report that to the police and bring a police report to visit for verification.

Statewide databases that allow for tracking of patient prescriptions, including prescriptions for all schedule II drugs.

REMS programs Fire the patient!

Photo by Julius Schorzman

REMS—What is it? Risk Evaluation and Mitigation Strategies are a way

to decrease adverse outcomes with these drugs. They include:

Medication guides with pertinent patient information

Black box warnings to alert the prescriber to potentially harmful side effects

Additional prescriber education, if needed For instance, “Dear Prescriber” letters, drug-company-

sponsored education, pharmacy registration

Risk Evaluation and Mitigation Strategies REMS is being proffered as a way to

decrease the risks associated with long-term opiate use/abuse—long-acting drugs were included first Morphone, morphine SR, hydromorphone

ER, methadone, oxycodone CR, oxymorphone ER, transdermal fentanyl and transdermal buprenorphine, morphine/naltrexone ER

Drug companies paid to educate prescribers

Will REMS Work?

FDA is asking that the training be mandatory for anyone with a DEA#

Advantages? OBVIOUS! Helpful to the patient, prescriber

Disadvantages? OBVIOUS! Though most prescribers are on board with the

idea….there is some hesitancy in investing time for training

The fear is that other drugs will be “switched to”

Photo by Ondřej Karlík

IR Products Recently Added to REMS

Fentanyl Products Approved products with the brand names

Abstral, Actiq, Fentora, Lazanda, Onsolis Indicated to treat cancer breakthrough pain in

opioid-tolerant patients Added to REMS because of high home use and

high potential for abuse or accidental misuse

Other Trends in Opiates Tightened controls for hydrocodone?

Schedule III to Schedule II? Still in the consideration stage….

More preparations that are opiate-only, with no acetaminophen Will help with liver issues, hurt with diversion/abuse

issues Oxycodone plus niacin (Oxecta): Causes skin

flushing and irritation if patient exceeds the prescribed amount

Oxycodone (Remoxy): Oxycodone that forms a gelatinous paste if the user tries to dissolve and inject it No more generic oxycodone formulations


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A bill introduced July 19, 2012 in the U.S. House would require most painkillers to have safeguards to prevent abuse

If pain medications did not adopt the safety features outlined in the bill, they would be removed from the Food and Drug Administration’s (FDA) approved list of generic drugs

Making Opiates Safer--Latest Legislation In the Meantime….

What other drugs are useful in the chronic pain patient?

Which drugs have proven track records? Which drugs may be prescribed by a

broader base of NPs? Anything new? Safer? Better?

Tramadol Tramadol (Ultram, Ryzolt, Rybix)

Weak agonist at mu receptors, also blocks NE and serotonin reuptake

Good PO for moderate to moderately severe ACUTE pain 50 mg; 100, 200, 300 mg extended release

Not a CS, but….avoid prescribing to patients with a history of drug abuse—diversion a problem

Many drug interactions—watch for serotonin syndrome, seizures!!

Try limit use to about 5 days Requires metabolism, and 5-15% of the population are

slow metabolizers Do NOT use ER tablets in patients with hepatic impairment!

Tapentadol (Nucynta) A moderate mu-opiate agonist and only effects the

uptake of norepinephrine into nerve endings No metabolic activation is required for analgesia

and there are no active metabolites This is an advantage over Tramadol It does not appear to cause the confusional states

sometimes associated with tramadol May be able to reduce morphine dose 50, 75, 100 mg Useful for ACUTE pain

Nonopioid Pain Relievers—Centrally Acting Clonidine (Duraclon)

Uses are for hypertension and for severe pain

Binds to alpha-2 receptors in the SC and disrupts impulses of pain signals

For pain relief, given by an implanted epidural catheter; usually given in combination with an opioid.

Causes profound hypotension and bradycardia Dexmedetomidine (Precedex) for acute use

Nonopioid Pain Relievers—Centrally Acting Ziconotide (Prialt)

Administered intrathecally only in patients with severe, chronic pain not controlled by other drugs (including intrathecal morphine)

Causes cognitive impairment and psychiatric syndromes as SE Hallucinations, mood changes, risk of suicide.

May take up to two weeks after discontinuance to resolve.


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NSAIDs for Pain Most widely used group of

drugs for pain Side effects include GI

bleeds/distress and renal and hepatotoxicity

No reduction of inflammation with acetaminophen

Watch use in children, in alcohol use, high BP, liver disease, renal disease

Photo by William Cho

Newer Formulations of NSAIDs Ibuprofen

Sprix nasal spray; Caldalor IV IV formulation (800 mg) reduces opiate

need by about 25% post-op No real worries about renal function since

use is short-term Acetaminophen

IV for acute pain, or combined with an opiate

Ofirmev; fast, penetrates CNS, anti-pyretic 1000 mg in those weighing >50 kg every 6 h

Droperidol Droperidol IV or IM has been somewhat

successful in opiate tolerant patients 0.625mg to 1.25 mg Pretreat with diphenhydramine to reduce

akathisia related to droperidol treatment. May be added to opiates significantly

reducing their effective dose.

Antidepressants for Pain Work best for neuritic or neuropathic pain,

less helpful for musculoskeletal pain Agitated or anxious patients do best with

antidepressants that are more sedating Most common SE are drowsiness,

constipation, dry mouth, blurred vision. Watch for Serotonin Syndrome.

Antidepressants for Pain BENEFITS

Not as much GI upset as NSAIDs May help with sleep May reduce depression associated with

chronic pain May relieve anxiety associated with pain May increase effects of other pain meds Are non-addictive Safety is documented

Antidepressants Commonly Prescribed for Pain TCAs: Amitriptyline (Elavil),

Desipramine (Norpramin), Imipramine (Tofranil), and Nortriptyline (Aventyl, Pamelor) Desipramine has lowest SE profile

SSRIs: Duloxetine (Cymbalta), Venlafaxine (Effexor), Mirtazapine (Remeron) Best profile for pain. Other SSRIs

not as effective for chronic pain.

Mirtazapine


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Anticonvulsants Used for Pain Gabapentin (Neurontin), Pregabalin

(Lyrica), Tiagabine (Gabatril), Topiramate (Topamax)

Good for neuropathic pain, pain due to nerve injury, sensory neuropathy.

May cause drowsiness, dizziness, report any vision changes!!

Anticonvulsants Used for Pain Carbamazepine (Tegretol) Valproic acid (Depakote) Phenytoin (Dilantin) Clonazepam (Klonopin) Lamotrigine (Lamictal) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Zonisamide (Zonegran)

New Updates on Seizure Drugs Gabapentin Enacarbil (Horizant) just approved for

postherpetic neuralgia—10% incidence Doses 600 mg bid Prodrug of Gabapentin; not interchangeable Somnolence, dizziness, suicidal ideation

Pregabalin (Lyrica) approved for neuropathic pain in spinal injury—the first drug for this condition! 40% of patients with SCI develop neuropathic pain Somnolence, dizziness, sedation, angioedema have

been reported Doses 150-600 mg daily

New Uses of Old Drugs for Pain Muscle Relaxants

Cyclobenzaprine (Flexeril)—this is really a TCA, so it has all the TCA side effects.

Carisoprodol (Soma)—now banned by European Medicines Agency (our equivalent of the DEA) due to abuse issues—watch for abuse potential!

Methocarbamol (Robaxin) and Metaxolone(Skelaxin)—older; sedation is main effect/SE

Orphenadrine (Norflex)—this is actually Benedryl, so sedation and inhibition of motor function will be seen.

New Uses of Old Drugs for Pain Tizanidine (Zanaflex)—an agent for spasticity that

shows some evidence for the treatment of chronic pain, musculoskeletal pain, and neuropathic pain. Alpha-agonist similar to clonidine; since it

causes significant sedation, should be reserved for night time use

Lioresal (Baclofen)—antispasmodic that is being used (off-label) for musculoskeletal pain. Sedation is side effect of note.

New Strategies for Pain Management Opiorphin: Blocks the endopeptidases

that normally degrade opiates—this would prolong their duration of action. These agents as stand alone drugs would have little abuse potential but….

Ibudilast: Inhibitor of glial activation, has some potential for neuropathic pain. May restore morphine tolerance. Also being tested for methamphetamine

addiction


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New Drugs for Neuropathic Pain TRPV1 channel agonists

This is where capsaicin works (transdermal, 8%)

8% patch is indicated for herpetic neuralgia Possible for migraine, pruritus, musculoskeletal

pain, osteoarthritis Endocannabinoid receptor agonists

These interact with the TRP channels and endorphin pathways; are neuromodulators on CB1 and CB2 receptors

Controlled studies are lacking

Treatment of Pain—Multimodal Therapies Opioids can help with ascending pain

pathways in chronic pain management. Plus an antagonist to deal with opioid ADRs

NSAIDs can be used to decrease prostaglandin formation centrally, and also to affect substance P and serotonin pathways.

Membrane stabilizing drugs such as seizure meds alter ion flux in nerve membranes, blunting depolarization, affecting both pain transmission and perception.

The Problem of Pain…Approached Clinicians are treating pain more aggressively

as a result of the Joint Commission standards, and this may lead to more adverse events.

BUT…using multi-modal analgesia (“balanced analgesia”)… Benefit the patient in that it can bring sedation,

pain relief, and reduce tissue destruction Benefit the prescriber in that it may mitigate

some of the adverse effects of opioids

Keep Approaching the Problem of Pain!

Keep up with drugs and safety issues Including REMS Plan for prescribers to mitigate

abuse/diversion Recognize that pain relief is multi-modal

This is good news for your patient This requires more knowledge, skill,

monitoring Other than new formulations, the drugs

have not changed much, but regulations of these medications may be in flux.

The Big News in Pain Management

Pharmacogenomics may allow for better prediction of response, of adverse effects—and may reveal the diverter!

Documents

Pain Management Handouts - Barkley and Associates Handout Samples/Full Handouts/P… · Pain Management Handouts 1 Pain Management for the Advanced Practice Nurse Elizabeth A. VandeWaa,